The egested intestine

The Annals of Medicinefor the Year 1802 are the source of today’s extraordinary goings-on. This case was reported by John Bower, a surgeon from Doncaster:

January 17, 1796: Ed. Cooke, aged 40, a day-labourer, was returning to his home, about two miles from Doncaster, between ten and eleven o’clock at night. Being in a state of intoxication, and having leaned upon the battlements of the bridge, he had, I suppose, fallen asleep, when the noise of a stage-coach coming upon the pavement, awaking him, he reeled from the causeway, and fell down, and a fore-wheel of the carriage passed over his body.

Stagecoaches were less heavy than the average family car, but had much thinner wheels. One of those passing over your body could do considerable damage.

On my arrival soon after the accident had happened, I found him complaining of great pain in his abdomen, across which, between the navel and pubis, was the mark of the wheel. There appeared no injury elsewhere. I bled him, and sent a solution of vitriolated magnesia.

Vitriolated magnesia (magnesium sulphate) was also known as Epsom salt, a commonly prescribed remedy at the time, often used to treat digestive disorders.

In the morning, I was surprised to find that he was gone home. He had got up early, and would walk; which, by the assistance of two people, and with great difficulty, he performed. I rode over, and found him in violent pain; his body greatly swelled, and very tense; pulse quick and weak; had a nausea, but no vomiting or shivering fit. By means of leeches, fomentations, &c. and keeping the bowels in a lax state for several days, he began to have favourable symptoms, and, in the course of a fortnight, was able to walk about a little.

Thins looked good at this stage, but then he took a turn for the worse.

He then complained of a weight at his navel, and said, that whatever he eat, seemed to do him no good. On the 17th day after the accident, in the evening, whilst sitting by the fire, he was seized with such a general debility, that they were obliged to lay him upon the bed, and he continued in that state for ten minutes: the next night it returned in the same manner; and on the following morning, he parted per anum with full fourteen inches of his intestines, apparently a portion of the ileum, with a part of the mesentery adhering to it; after which, he had a lax stool, more in quantity than he ever got quit of at one time since the accident.

The stuff of nightmares. The patient had discharged a fairly substantial chunk of his own small intestine with his bowel movements. The mesentery is a membrane which connects the intestine to the abdominal wall – and, since the appearance of this article at the end of last year, has been recognised as an organ in its own right.

He continued in a lax state for two or three weeks, (though he could retain his faeces) when a tumour appeared below the navel, and in a few weeks broke, and discharged a large quantity of matter, having a yellowish tint, and a faint smell of faeces.

This is an unfortunate and unpleasant complication. The ‘tumour’ was a hernia, a break in the abdominal wall through which a loop of intestine began to protrude. Eventually the thin covering of skin broke, causing an enterocutaneous fistula – an anomalous opening between the bowel and the skin.

At times, his body would be so much distended with wind, as to force out the discharge to the distance of a yard or two.

Charming.

He got strength gradually, and, in harvest-time was able to walk into the fields. When winter approached, he was obliged to keep in the house, and frequently in bed, as three or four small tumours appeared at different times, and broke; so that now there are five orifices.

Five!

The two first which broke, are a little above the pubis; the third, about one and a half inch below the navel, and the two last just above Poupart’s ligament.

Poupart’s ligament is in the groin. Two years after the initial accident, Mr Bower visited the patient:

Feb. 1798 — I called to see him, and found him in bed, where he had been confined several weeks: — said that his legs had been greatly swelled, but were then much settled: — that he had five or six stools daily, but that his appetite was good.

The surgeon checked up on his patient at intervals; this is his final report on the case:

Nov. 2. 1801 — The following I shall give you verbatim, as I wrote down from the man’s own account of himself. He came over to see me at Doncaster; — is a great deal stronger; — appetite very good; nothing disagrees; — no stools soon after eating; — generally six stools in the twenty-four hours; sometimes more; often he is obliged to get up two or three times in a night; other times, can lie for several nights together, without being disturbed; — stools loose; not offensive; — discharge constant; but more at one time than another; — two orifices open; — wind emitted from them often very offensive; — uses a deal of walking exercise, being made Pinder of the village…

The ‘pinder’ was the person whose job it was to round up stray animals.

… seldom free from pain in his body; most when costive; keeps grumbling and rolling about, and twitching for half-a-day together; but is easier when he has parted with wind, which comes more through the orifices than per anum: — Discharge mostly yellowish; sometimes brownish: — orifices never all healed up: — once in ten days or a fortnight, is not so lax: — stools not so much in quantity, being hardened, though the same in number: — has had an ulcer in his right leg for four years, which increases in size ; discharges a great deal sometimes, and thinks he is easier in his body. — Lives chiefly upon milk and bread and vegetables: — feels the belt when he lives well, that is, when he gets any meat and malt liquor; then has not so much pain in his bowels, nor parts with so much wind, nor has so many stools.

This does not sound an entirely happy existence.

There is a final note appended to this report, a letter from one ‘H.L. Thomas of Leicester Square’. I cannot find a trace of this person, but it appears to be a London surgeon to whom Mr Bower had appealed for a second opinion. This was his reply:

I have given a very particular examination to the portion of intestine you were so obliging as to send for my inspection. There can be no doubt of its having belonged to the human subject, and is, I believe, a part of the ileum, or the lower end of the jejunum. I can account for this strange production in no other way, than from intussusceptio, the strangulated portion having sloughed off. This supposition will be further strengthened, if the intestine at the time of its expulsion was found inverted.

In this condition, known today as intussusception, a section of bowel folds into the adjoining section, like a section of telescopic tubing collapsing on itself. This can obstruct the blood supply to the affected section, causing necrosis (tissue death). It is rare but not unheard-of for a section of bowel to die and slough off, as described by the London expert. But – as a correspondent in the Edinburgh Medical and Surgical Journal later pointed out – intussusception is a rather unlikely diagnosis in this case, since the cause of illness was a traumatic injury. It seems much more likely that the passage of the stagecoach wheel over the abdomen caused serious injury to a section of bowel, which subsequently became necrotic and ‘came loose’. It is quite amazing that the intestines should continue to function even partially after such a catastrophic occurrence, but there are plenty of other examples in the literature.